2025 HFSA Contemporary Issues in Heart Failure - OnDemand-Management of Fluid Overland and Renal Dysfunction (Part 2)

Video Transcription

Video Summary

This lecture discusses management strategies for fluid overload and renal dysfunction in acute heart failure, focusing on diuretic resistance and therapeutic approaches beyond loop diuretics. Key points include:<br /><br />1. Traditional belief linking low cardiac output to worsened renal function and diuretic resistance is challenged by studies showing no direct relationship, indicating inotropes to increase cardiac output rarely improve renal function or diuresis except in classic cardiogenic shock.<br /><br />2. Continuous loop diuretic infusion, despite theoretical advantages (avoiding post-diuretic sodium reabsorption and better dose delivery), has not shown superior clinical outcomes compared to bolus dosing and may worsen diuretic resistance.<br /><br />3. Adding thiazides as adjuncts to loop diuretics yields modest additional diuresis but increases risks of hypokalemia and worsening kidney function; evidence suggests a potential mortality signal, warranting cautious use.<br /><br />4. Acetazolamide shows limited benefit and is likely less effective in patients already on SGLT2 inhibitors, which themselves provide safe, modest natriuresis with favorable electrolyte and neurohormonal profiles and synergize with loop diuretics.<br /><br />5. Ultrafiltration effectively removes fluid but is limited by cost, practicality, risks, and unclear ideal patient selection, often reserved for severe cases refractory to pharmacotherapy.<br /><br />6. Low-dose dopamine demonstrates physiologic renal benefits but no consistent clinical outcome improvement; it may be considered when other options fail.<br /><br />7. Hypertonic saline combined with loop diuretics may enhance diuresis and mitigate renal dysfunction, but its mechanisms are unclear, and regular saline may be a simpler alternative.<br /><br />The overall strategy emphasizes aggressive loop diuretic dosing, cautious stepwise addition of second-site diuretics, early incorporation of SGLT2 inhibitors, selective use of dopamine or saline, and reserving ultrafiltration for refractory cases. Monitoring and balancing benefits versus risks is critical in managing complex cardiorenal dysfunction in heart failure.

Keywords

acute heart failure

fluid overload

renal dysfunction

diuretic resistance

loop diuretics

SGLT2 inhibitors

ultrafiltration